Auto Withdrawal Form

Please fill out the form below and attach a voided check. These are entered once a month (on the 14th) and the first withdrawal begins the following month on the 10th. You will still receive a statement in the mail, only it will state "drafted" on it so that you will know what to expect to be withdrawn from your account.

Property Address (required)

ELCO Account #: (required)

I (we) hereby request and authorize East Larimer County Water District (ELCO) to make monthly withdrawals from my (our) Checking or Savings account (select one) for the payment of water service to the property described below. The financial institution named below will debit the same to this account. (required)

Account balance will draft on the 10th of each month.

Today's Date (required)

Person Requesting ACH (required)

Email Address (required)

I (we) understand that is my responsibility to notify ELCO if I change banks by submitting a new form. My (our) signature below authorizes ELCO and my financial institution to electronically debit my bank account on the 10th of each month. I understand that if funds are not available, I (we) may be charge a NSF fee of $15.00 per transaction. This authorization will remain in effect until I have notified ELCO to terminate the ACH.

Please attach voided check here (required)

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